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British Gestalt Journal © Copyright 2018 by Gestalt Publications Ltd.
2018, Vol. 27, No.1, 31–39
Hidden figures: a somatic and relational approach to healing
OCD
Stacey Klein
Received 3 April 2017
Abstract: This article aims to show that Obsessive–Compulsive Disorder is not a disorder
but a creative adjustment and a meaningful coping response to an early traumatic
environment. Stemming from her long-term experience practising cognitive behavioral
therapy, the author describes how this approach is often ineffective and contraindicated for
traumatised individuals and introduces a longer-term somatic and relational approach based
in Gestalt therapy. The author shows that the reinstatement of a client’s stalled separation–
individuation process is at the heart of healing OCD. The phenomenological unfolding and
treatment of Obsessive–Compulsive process in the present moment is illuminated through
several case studies, each one demonstrating an aspect of treatment including: the use
of Winnicott’s ‘transitional object’ as metaphor to deconstruct fixed figures and expand
the contact boundary, the relationship between OCD and preoccupied attachment, and
the use of mind–body interventions derived from developmental somatic psychotherapy.
The author emphasises that viewing OCD as a process rather than a pathology can help
drastically to reduce clients’ shame and reorganise the relational field so healing can occur.
Keywords: Obsessive–Compulsive Disorder, creative adjustment, trauma, cognitive
behavioral therapy (CBT), relational, preoccupied attachment, separation–individuation,
developmental somatic psychotherapy (DSP).
‘We hold in the places we weren’t held.’ (Ruella Frank client to his feared situations. Trained as a Gestalt and
(personal communication)) psychodynamic therapist, I felt that CBT completely
missed the essence and depth of these clients’ suffering,
‘We’re children of God before we’re children of our so while I continued in this setting I focused on
parents. It may actually take some time for an infant discovering what the missing components were, in
to de-infinitize… To actually come into the realization order to help these clients heal.
that I have to be where my body is, that my body is this Seven years ago, I began treating clients with OCD in
bounded packet, really takes quite some time and some private practice. Several clients from around the world
sophistication.’ (Michael Eigen, in Molino, 1997, p. 106) contacted me because they feared exposure therapy or
because after completing CBT their symptoms returned
Introduction: the need for a new in new configurations. (‘I resolved my “contamination
OCD” but now I have “harm OCD”.’) I unintentionally
treatment approach retraumatised one client who insisted we do exposure.
After ten years of administering cognitive behavioral At that point, it finally clicked for me that all of these
protocols (CBT) to adults and children at a large clients had felt traumatised by their early environments
teaching hospital in New York City, I joined a CBT to varying degrees. Their OCD symptoms were
program there for adults and children with Obsessive– creative adjustments serving to contain their encoded
Compulsive Disorder. I did this with some reluctance childhood relational traumas. Their symptoms held
given OCD’s reputation for being incredibly challenging them together when their environment could not.
to treat. CBT clinicians acknowledge that we need alternate
Out of my large caseload, only one client experienced approaches for OCD, since one out of four clients refuse
mild relief through CBT. The rest were too terrified exposure treatment altogether (Maltby and Tolin, 2005)
to comply with ‘exposure and response prevention and 20% drop out of treatment (Schruers et al., 2005).
therapy’ (ERP), which involves gradually exposing a I believe CBT has its merits and I adapt aspects of it32 Stacey Klein
in my practice; however, despite a few limited recent and uncertainty. To relieve or undo the distress caused
studies (Doron et al., 2009; Rezvan et al., 2013), I have by these obsessional themes, a person may engage
not found it helpful for my clients. One major limitation in rituals (compulsions). Typical obsessive thoughts
is that CBT takes clients’ fears literally (‘you fear HIV, include fears of harming oneself and/or others,
let’s touch needles’) when, undoubtedly, their fears are becoming contaminated by germs or contracting
relationally shaped symbolic communications (e.g. ‘I’m diseases or being imperfect (forgetting things, not
terrified of expressing my anger towards others’), even noticing errors). Compulsions can include hand
if also genetically influenced. Because it is considered washing, avoidance, ordering objects symmetrically,
evidence-based, CBT has been marketed as the ‘gold tapping, or seeking excessive reassurance, and may be
standard’ in OCD treatment, which has created a experienced only mentally.
landscape of suspicion for clinicians who are not doing Typically, people diagnosed with OCD spend
ERP and shame for clients who feel like failures if they many tortured hours of each day stuck in painful
choose to pursue different treatment. CBT misses the obsessive–compulsive loops characterised by noticing
overwhelmingly relational, traumatic and somatic a distressing thought and then negating it through
issues that shape the development of OCD. Chronic some ritualised external or mental action to calm their
dissociation, affect dysregulation and a diminished anxiety. For example, if someone has a blasphemous
sense of embodiment – all major indicators of trauma – thought about God, which they feel is ‘bad’, they may
have been underestimated and misunderstood because negate it by mentally thinking a ‘good’ thought about
of the larger psychiatric world’s current reliance on God. This cycle is both exhausting and terrifying, often
CBT and narrow bias towards anything that cannot be causing severe functional impairments interpersonally,
standardised or has ‘inadequate conclusive research’ professionally and internally.
(Huppert et al., 2005). Furthermore, CBT seeks to In this article, I reframe OCD as ‘OCP’ – obsessive–
eliminate symptoms that serve as the fragile thread that compulsive process – because I see it as a meaningful
keeps many clients from unravelling into psychosis. coping style, and labelling it a disorder risks further
I have found that a somatic and relational approach shaming these clients, many of whom have already
based in Gestalt therapy has been highly effective with introjected enormous shame.
these clients, substantially reducing the intensity of
their symptoms and enabling them to live more freely.
How an obsessive process forms
The work is complex and a client often needs to invest in
a year or more of psychotherapy; however, he can heal. We all call on OCP periodically when the ground
What helps heal OCD is the therapist’s belief that the presents larger threats than we are able to face.
client was never broken: he was traumatised. Holding Reorganising a messy sock drawer or repeatedly
the possibility of healing in the field, the therapist checking our bank account acts like netting in the
reshapes the client’s view from one of intrapsychic gap between this known moment and the unknown
blame to compassion for his field experience. next. These rituals block out the greater threats of
In this article, I aim to illuminate the gaps missed the background, enabling us to narrow and simplify
by CBT and psychodynamic approaches and to offer our experience to more manageable figures in the
new theoretical understandings (developed through foreground. They temporarily contain and soothe our
phenomenological inquiry and Gestalt experiments) fears, offering us an illusion of control, mastery and
and directions for healing. a sense of consistency when other means of reliable
OCD is a contacting style, a meaningful co-creative support are lacking.
expression that arises from a traumatic relational field. An OCP becomes a fixed and painful way of relating
Immersed in the OCD experience, I unexpectedly – a habitual response – when the environment is
discovered and healed traumatic pieces from my own repeatedly experienced as traumatic, i.e. filled with
childhood. When clients learn to understand their ‘overwhelming experiences that cannot be integrated’
obsessive–compulsive patterns within a safe holding (Ogden and Fisher, 2015, p. 29). When parents are too
environment they can disentangle their life energies filled with their own unconscious traumas or unable to
from their traumatic narratives and reorganise their access a felt sense of comfort from their own history,
entire relationship to life. parts of the child’s emerging energies – her feelings,
sensations, impulses (id functioning) – are not received
and fail to assimilate. Rejecting in herself what felt
OCD: definitions and functions
unwelcome and often harmful to her caregivers, these
OCD is traditionally defined as the experience of having rejected feelings become unconsciously paired with a
unwanted, repetitive, intrusive thoughts, images and sense of dread or chaos. The child develops a fear of
impulses (obsessions) that cause anxiety, guilt, doubt these feelings which is the hallmark of OCD.Hidden figures: OCD 33
To protect herself from drowning in this state of to remain confluent with his parents’ expectations. His
inchoate dread, and primarily to create a sense of OCP becomes a mother substitute and though it is his
safey and control, the client creates her own life-saving best attempt to regulate himself, it also expresses his
container by binding her original fear with an OCP – a excruciating dilemma: ‘I can’t live with you or without
set of stories, rituals, ‘repetitive loops’ (Jacobs, 2003, p. you’. A client’s reluctance to push away and release his
38). She slams the lid shut so she can experience herself thoughts also represents his inability to push away and
as ‘going on being’ (Winnicott, 1975, p. 303), enclosing release the mother he could never safely attach to.
herself within some known, fixed, safe lines. Though this For example, Jane, age thirty-four, had struggled
container imprisons her, it enables her some space, some with OCD since childhood. Raised as a devout
place to withdraw into and push away from the original Christian, she sought therapy because she felt plagued
terror. Lost to her conscious awareness, she experiences by frantic existential questions about the meaning
these dissociated thoughts and feelings associated with of life and relational dilemmas (‘Am I bad for doing
the original fear situation as hostile intruders; they feel that?’). To counter her anxiety, Jane engaged in
alien to her because they were disowned. compulsive prayer to appease God for her being a
In the face of both ‘the too fixed figure’ and ‘the ‘bad Christian’. These reassurance-seeking rituals
too charged ground’ (Perls, Hefferline and Goodman, intensified when ‘something felt off’ between Jane and
1951/2009, p. 59; hereafter PHG), the client creatively someone she loved. We made the connection that these
adjusts by manufacturing her own alternate world of rituals emerged as a mother substitute. When Jane
illusory figure and ground, thus at least setting out to was a child, her mother did not know how to soothe
‘do something’ to counter the unbearable helplessness her adequately, instead encouraging Jane to ‘see what
and creating some meaning and order rather than the Bible said’. Sensing her mother was depressed,
losing herself to a meaningless world of terror. The Jane recalls confessing to her when she felt she did
more chronic and pervasive the overwhelm, the more something ‘bad’, to gain reassurance that she was ‘a
reliant she becomes upon OCPs as her reference point. good girl’. She also recalled soothing herself as a child
It is important to appreciate the resourcefulness of this by lining up her dolls every night until things felt just
defence because even if the client is fighting a losing so. ‘If they were in order, I could feel in order and get
battle (with OCP it ultimately is), it is a battle she can through my day.’
face, devote herself to and mobilise against. This offers During a session, when Jane was panicked and
her some sense of agency and some sense of other, trying to figure out her feelings, we slowed down and
some companion to relate to in a world permeated by breathed together, and I invited her to sense her body
horrific isolation. and go deeper into her experience. She allowed her fear
In more severe experiences of OCP, clients not only and uncertainty to emerge and develop into feelings of
experienced their feelings as unwelcome, but they also sadness, though she felt terrified (‘What if I drown in
faced intrusive parental hostility and criticism which my sadness?’). When I sat beside her to comfort her,
left them feeling chronically petrified and unsafe. she sobbed for the first time, expressing how painful
it felt to be comforted, ‘because this comfort feels like
Preoccupied ground, preoccupied home – like something I never got – and now I’m afraid
I will like it and it will end, so I never go to that place
attachment because I fear what if I never find it again?’
Clients with OCPs are gripped by an energy of Sensing her body more closely helped Jane learn
preoccupation. Their preoccupation manifests in their to recognise how quickly she jumped to ritualise in
struggle to release the false figure in the foreground, moments of uncertainty. We worked with this place
which they believe is the true cause of their distress (e.g. by inviting the scared child part of herself forward
‘if only I could figure out whether I am a paedophile or so it could voice its fears and helped her access an
not’). This foreground conflict initially needs to remain internalised comforting presence – a way to physically
unresolvable until clients feel safe enough to approach and verbally soothe herself through those moments.
the unarticulated and painful hidden figure in the We also addressed Jane’s need to seek reassurance
background that truly motivates their desperate search from an external authority (e.g. the Bible) by helping
– their ambivalent attachment. her begin to trust her own inner knowing.
The hidden figure impinges on the client constantly Underlying OCPs is the loss of a longed-for, reliable,
and unconsciously so that he lives somewhere between comforting other who never came, the despair that
the figure and the ground (which never empties). support will never come and the grief underlying the
Unable to reject or resolve the ambivalence he feels belief that one can only rely upon oneself. It can take
towards caregivers he also depends on, he withdraws a long time before clients are able to touch this place
from fluid contact with himself into his OCP in order in therapy.34 Stacey Klein
The space between and around through being securely held, we become the master of
experience our experiences rather than their captive.
I believe that in the obsessive experience, the
A key characteristic for many people with OCPs is symbolisation process partially fails to complete itself,
their inability to feel space around their experiences even if it also helps organise the client (as it does when
and between themselves and others. Things and people later life trauma causes an individual to form an OCP).
feel too close up, fused with oneself. There is a lack of a OCPs then paradoxically come to symbolise what failed
sense of boundaries and separation. to happen; they are a child’s depiction of the ‘stories
To calm their terror, clients with OCPs employ mental about the bad feelings that never went away’; fairy
vigilance to try to access a feeling of ‘just rightness’, tales deprived of their happy endings. OCPs represent
when what is missing is a full-body experience of unrequited relational and energetic dilemmas – the
letting go. When a safe other makes space for us, we hug that never came, the mistake that could not be
can soften into their presence and/or their bodies and forgiven, the impulse that lost its way.
into our own, and a sense of space opens up within us. In the obsessive field, one’s fears remained literal
In this space, we release our pressing internal contents, because one’s feelings never lost their initial threatening
sense our minds moving to the background and fully charge allowing them to mature and become just
inhabit ourselves. Repeated moments like these contain feelings. If one never learned that ‘a hug can fend off the
and absorb us, transforming energies that previously fear of death’ (Francesetti, 2017, p. 11, original italics),
felt threatening into tolerable ones (Bion, 1977, p. 27). then one is always literally feeling that one is at war with
They create a sense of an ‘other’ – who is separate from death. When a client’s fears fail to lose their power, he is
us – a container for our contents (and therefore an left with a lingering horrific darkness that symbolises
experience of self) – both of whom are large enough his inner and outer uncertainties. He projects his fears
to hold our experiences. (Bion’s theories substantiate outward so that his world feels filled with germs and
this, though not with specific mention of OCD.) This demons, in which he has to be ever vigilant because
experience of self and other as container reveals that danger seems to lurk around every corner. This
we are not our fears but that which holds them – and terror also remains inwardly. Fearing that something
when these figures are released, we and the other go on. disturbing can jump out at him at any time from the
Contacting then feels safe. inner ground of his being, he is afraid of the space that
These moments of ‘final’ and ‘post contacting’ were emerges between this figure and the next because he has
lacking for people with OCPs. Lacking a safe and never lived in a non-preoccupied state. These fears force
reliable enough ground of an ‘other’ from whom to find him to withdraw into an alternate universe where he is
relational support and the shift in perspective which suspended and immobilised between worlds – afraid to
space affords, these clients experienced little distinction move forward into life or inward to explore his psychic
of figure as separate from any ground – as self separate life. His failure to symbolise reflects an environment of
from an ‘other’ and from their arising experiences – early trauma. When a child has to be so hypervigilant,
and therefore little observing ego. They feel as if they he is too afraid to play or explore. Therapy works to
are their experiences (which is why they attach to every unearth his lost narrative and fearful parts to help
thought). Many live primarily in this one terrorising them mature from partial to full symbolisation.
part of themselves that has hijacked them so that their
fear never truly finishes. The transitional object: the use of
metaphor
OCPs as partial symbolisations
I began to frame OCPs with some clients as metaphors
The capacity to symbolise – ‘to evoke the absent for transitional objects (Winnicott, 1971/2005). OCP
object, to anticipate the future, to conceptualize, is a client’s contact boundary regulator. Like a child’s
and to communicate’ (Meetings of the New York beloved teddy bear that she takes with her to help
Psychoanalytic Society, 1971, p. 383) – is an navigate the transitions in her life and allows her parents
indispensable process for children’s developing to interact with, the client’s OCP is like a transitional
relationship to life. It is the process by which object. She too brings it with her to the therapist in
something comes to stand for something else and the transitional space or the contact boundary, but the
therefore matures from being the thing itself. When difference is that hers is a stalled symbol, which fails to
a mother’s loving presence came often enough, we can represent the mastery and joys that are normally born
symbolise her internally by recalling a felt sense of of the separation process (ibid.). Instead her symptoms
her (Stern, 1985). A shark puppet comes to stand for express the distress that immobilised her transition
and be a vehicle for a child’s anger. Through play, as from confluence with her family to differentiation.Hidden figures: OCD 35
While most clients feel intense shame in sharing breakable he felt. It became our shared metaphor, a
their symptoms, many express endearing attachment transitional object representing the fragile nature of
to this inanimate symbol of their experience because it our contacting, and a physicalisation of his OCP and
still offers the vehicle through which they are ‘waiting his inability to release this fixed figure.
to be found’ (ibid., p. 63). I introduce clients to this The vase metaphor opened up exploration of
metaphor saying, ‘It’s sort of like a security blanket George’s childhood experience of having to be
though not quite, because it also causes you distress. confluent with extremely high parental expectations.
But it is familiar and it helps you feel safe when you He had to become a successful lawyer, and getting sued
don’t know how else to be with your feelings.’ I also was a huge shame. ‘I realise the core of my distress was
make the link that OCPs intensify when the ground my childhood. There was no me. There was a false me.
begins to push forward to help clients gradually make It was all about them until something in me couldn’t
the connection, ‘Oh, I must be anxious about something take it anymore.’ George realised that his whole life
else right now if I’m in this loop’. As a client develops was organised around a fixed idea of ‘not fucking up’
trust in the therapeutic alliance, she will allow you to symbolised by not ‘breaking the vase’.
gently nudge, transform and revitalise this weak figure George’s HIV fears of mistakenly contracting a
and deepen the contact boundary into something ‘shameful’ disease symbolised his fears of being rejected
livelier, facilitating the transition from the literal to the and shamed. Somatic experiments with proximity
symbolic. For example, instead of narrowly spending (e.g. me entering his personal space) revealed that
the session recruiting you to help her figure out if she contracting HIV also symbolised his fear that people
contaminated someone, you widen the ground and ask can invade and harm him, revealing his inability to set
her what it feels like to believe she is ‘contaminated’, boundaries between himself and others because his
gradually creating space for new figures to emerge psychological space was never honoured.
from the ground – e.g. her sadness – so that her story Initially, I used the vase as a metaphor for his fearful
can reorganise. Talk of transitional objects evokes contacting style in our sessions. I would ask him about
powerful imagery and remembrances of security our connection or his feelings and he would say, ‘This
blankets, stuffed animals and clients’ experiences isn’t related to my OCD; can we get back to it now?!’
of often pronounced separation anxiety and terrible His sense of humour enabled me to redirect the
ambivalence. OCPs are their ambivalent companions. sessions and ask him, ‘Would you be willing to put the
vase down for a few minutes and see what happens?’
Gradually, he saw his fear and allowed more space
Case example
between his attempts to stay in control and his ability
George, a man in his sixties, struggled with anxiety to be more vulnerable with me, enabling him to face
and some OCPs around perfectionism since childhood. the greatest fear in OCP, the fear of being disturbed
He struggled with some OCPs around perfectionism, (Dan Bloom, personal communication, 2015) and
which intensified eight years ago when, as a successful disorganised through contacting. He now relies on
corporate lawyer, he was sued several times. This led OCP much less and allows himself to be more open
him to ‘have a breakdown’ (he had to stop working, to his experience in session. The space between us
his life fell apart) resulting in the development of (the contact boundary) has opened up from fixed to
PTSD and simultaneous obsessive–compulsive more spontaneous contacting and he has been able to
fears of contracting HIV. His compulsions included tolerate his feelings more, experiment with polarities
avoiding close contact with all people (due to fears (‘being the irresponsible and careless bad boy’) and
of them having open wounds and giving him HIV) ritualise less. Though his symptoms have dramatically
and needing constant reassurance. He also drank abated, George acknowledges recovering from OCD is
heavily to manage his anxiety. George received several a slow process: ‘My real “exposure” now is accepting
outpatient and inpatient CBT treatments but found the the messiness of my feelings, of real life and learning
exposures of hugging contaminated needle containers I can cope.’
too frightening. He has been seeing me twice a week Conceptualising and physicalising OCP as a
for four years. transitional object or companion allows the client to
Initially, George insisted his fears of contracting HIV deepen his understanding of his conflict and to do
were literal, rarely allowing me to shift the topic away what he could not do as a child – regulate how much
from his fears in order to have him sense his body. One contact he wants instead of feeling compelled to shape
session, he shared a realisation that he feels as if he is himself around others. This offers him both deep relief
carrying a fragile vase around wherever he goes which and a sense of agency.
he can never put down. He expressed fears of dropping
it and breaking it. The vase was a metaphor for how36 Stacey Klein
Somatic pieces of the work children, these clients felt they had to sacrifice standing
their ground to preserve a connection to their parents.
Noticing and experimenting with the qualities and They all shared fear of harming a parent – usually
functions of a client’s habitual movement patterns mother, though sometimes father – coupled with
reveals hidden figures that represent a client’s preverbal chronic vigilance to ensure no further harm occurred
kinaesthetic learning, which can be less accessible to the parent. These experiments revealed the presence
through talk therapy. Developmental Somatic of unhealed multigenerational or ancestral wounds
Psychotherapy (DSP), developed by Ruella Frank, which crowded the early field, and which these clients
defines six movement patterns that are co-created in absorbed as children. Hooking into the wounded child
a child’s first year. These patterns are physical and parts of their parents and often their experience of the
relational supports for contacting and reflect how we parent’s ambivalence about their separation, they felt
learned to inhabit and shape our bodies in relation to too responsible and unable to disengage from their
our parents. Helping clients identify and strengthen parents and their parents’ unassimilated fears.
these patterns strengthens ego functioning and These clients struggled to access their push; their
decreases reliance on OCPs. Here, I briefly highlight necessary energy for establishing their difference from
the push pattern because of its striking diminishment others compromising their sense of agency and active
in the obsessive–compulsive experience. initiative. Pushing includes the ability to say no, to
The extent to which we can push informs us how walk away from, take space, establish boundaries and
available and reliable the other was for resistance and express anger and disgust. It enables us to protect
feedback, how easily we could take space from and and prioritise ourselves and feel a sense of privacy to
negotiate our distance and differences from others in our experiences.
our families (Frank and La Barre, 2011). When pushing Clients with OCPs often describe feeling as if they
is diminished, we feel uncontained, helpless and fused ‘lack skin’, ‘feel raw and exposed’, ‘wished I had some
with our experiences and with others. armour’, or feel ‘too porous’, therefore their fears that
‘things can just get in’ make sense. Movement work helps
Pushing: the process of separating and them develop a felt physical and energetic experience
developing agency of boundedness (a sense of skin), enlivens their sense
of self as active agent/doer and provides experiences of
The push pattern has also been figural in my own power and satisfying contact and release. ‘Acting the
life. I had difficulty separating from my mother due aggressions, the organism fills out its skin and touches
to unassimilated multigenerational wounds in my the environment without damage to the self’ (PHG,
family. My grandparents were Holocaust survivors 1951/2009, p. 345, emphasis mine). When pushing
and so in our family the experience of separation was experiments are adapted to provide clients with more
tantamount to death. Having explored the push pattern feedback than they experienced growing up, they begin
in years of bodywork sessions, I became curious about to differentiate between the past and the present, so
its potential relevance in helping my clients. I adapted that their exaggerated fears (that their aggression is too
an experiment from the DSP model to explore what powerful or persecutory or that their actions are too
my clients’ movement patterns revealed relationally. heavy for others) can reconfigure into a safe outward-
The client and I would face each other and play with moving energy. The ‘magical thinking’, ‘omnipotence
pushing a small ball between us, as a way of sensing of thoughts’ and ‘overvaluation of thoughts’ (the belief
how we meet one another. that thoughts are equivalent to action) (Freud, 1955, p.
What I discovered when I gently pushed the ball 86) that define OCPs are gradually transformed.
into their personal space was that over thirty clients Somatic interventions invite clients to claim and
who were struggling with OCPs expressed a startling occupy more of their bodies, awakening them to a sense
and repeated commonality in different ways. Despite of their body boundaries and, therefore, a felt sense of
apparent discomfort, all of them avoided pushing me their bodies (self/ego) as containers for their feelings.
away, allowing me to intrude on their personal space. Both children (for whom unresolved separation
While the relational field with each client was unique, anxiety often expresses itself through OCPs), and
in exploring their responses, all of them revealed the adults who learn to push more by experimenting with
same fear of harming the other through separating setting boundaries, in time, rely less on OCPs because
(pushing): ‘I don’t want to push back because I’m afraid they learn that life feels safer when we more clearly
I will hurt you’; ‘I feel like I have so much power to hurt sense our bodies and our sense of agency. The energy
you’; ‘I can’t protect my space with you, just like I can’t that was bound up in fear and confluence becomes
with my mother. I’m afraid to hurt her (or anyone) after available for creating powerful lives of their own and
all she’s been through, even though I feel so angry.’ As clearer, more vigorous figures.Hidden figures: OCD 37
Therapy suggestions entitlement to comfort and fear-free living. Focusing
on how their OCPs deny them the lives they long to live
OCP is a container for clients’ unassimilated traumatic can strengthen their motivation to tolerate the feelings
experiences when another safe container was not underlying their beliefs.
available. Because these clients’ traumas were chronic Gestalt therapy is a good modality for treating OCPs
and developmental, there was no single defining because of its expertise in working with moment-to-
event. Therefore, CBT research that administers self- moment unfolding process and helping clients notice
report questionnaires to pinpoint discrete ‘Criterion when they leave the present moment to ritualise,
A’ trauma events entirely misses the point, because though sensitivity to trauma and dissociation is key.
people with OCPs are dissociated from their traumas Gestalt’s emphasis on somatic experience is essential
and cannot name them. Their trauma was that they for these clients because of their diminished sense
never felt safe enough to be themselves. Their trauma of embodiment. Though not all clients are initially
symptoms include terror and dysregulation when receptive to somatic work, over time most become
certain feelings arise, a belief that the world is ‘more open to sensing when they feel dysregulated and
dangerous than safe’ and a tendency to scan for learning how to self-regulate through breathing and
threats to their survival. When triggered, many clients being present together. This helps unpair their arousal
exhibit shallow breathing and an inability to take in from their fear stories, and replaces attempts to centre
the reassurance they repetitively ask for because they themselves conceptually through thoughts and rituals
cannot shift out of a state of fight or flight and access with centring in their bodies and in relationship.
a calmer state of being – a parasympathetic response. Holding the notion of a transitional object can help
Feeling terrified, they vacate their bodies for their clinicians feel less pressured to ‘fix’ these issues, which
minds, staying on the surface of their experience, afraid these clients push for.
to go deeper into their feelings and trust themselves. Besides the safe therapeutic alliance, clients need
Their curiosity for life remains undiscovered because tools that help strengthen their sense of self as container
when survival is foreground, curiosity cannot emerge. so they can better navigate the feelings of uncertainty
Most do not meet the full criteria for PTSD and I that surface as they gradually release their rituals. Some
believe this is because OCP contains the traumatised tools include: Gestalt exercises on orienting, strategies
parts of the self. for shifting mind and feeling states and creating space
Therapy with these clients is like taking them by the from thoughts (taking walks, breathing, ‘flow’ activities,
hand and nudging them out of the narrow tide pools meditation), affect tolerance, work with movement
they got stuck in, escorting them back into the wider patterns, and creative experiments in session designed
river of life by teaching them that feelings do finish to disorganise and loosen fixed figures.
and that life is safe enough to be lived. This shift in Therapy can be very frustrating when clients are
perspective – from a state of hypervigilance to a life stuck in obsessive–compulsive loops. Appreciating
that is enjoyable – is not, as CBT posits, something the functions of these patterns helps establish safety;
one just easily surrenders behaviourally, because it however, therapists also need to chip away at clients’
is an entire rerouting of a client’s sense of self and stories by introducing the notion that their OCPs
a life organised around fear and fixed beliefs. These symbolise feared relational dilemmas. When they
beliefs are held on multiple levels of one’s experience trust us more, clients will allow these inner ‘hidden
– somatic, cognitive, affective and interpersonal; children’ to gradually peek out so we can slowly help
therefore, therapy needs to attend to all of these levels. them contact these lost feelings and reorganise how
Releasing rituals requires clients to push away from they contact us. The trick is finding creative ways to
what was familiar (including a complicated family widen or deepen the exploration. Because in OCPs
connection), propelling them forward into a new life. the traumas are pretty dissociated, these processes are
(These clients struggle most with transitions.) If clients repetitive but meaningful. Through attention to the
have not been helped to carve out a new life structure unfolding process in session, therapists can help clients
for OCP-free living, they will feel as if they are moving make clearer links between their symptoms and their
forward into a terrifying abyss and will just recreate feelings in the transference (e.g. ‘I think I’m feeling the
their OCPs. urge to hand-wash right now because I’m afraid to tell
An additional challenge is that clients’ fixed ideas you I’m angry at you’).
are highly syntonic. Since aligning with fear and Therapists need to be very aware of their
doubting themselves always felt safer, loosening fear countertransference responses around aggression (i.e.
structures will initally ‘feel wrong’ to them and they defensiveness, a need to be right or to retaliate when
will have to tolerate these fears of uncertainty. Therapy feeling criticised) so they can not only contain but
involves helping them develop self-compassion and an also be alert for opportunities to repeatedly affirm,38 Stacey Klein
encourage and invite a client’s buried impulses to traumatising. This co-creates the obsessive field
differentiate and aggress. Therapists need to be experience. Additionally, people with OCPs would
comfortable allowing clients to push them away so benefit from a programme tailored to their own unique
clients can see their therapist ‘survives destruction’ set of struggles.
(Winnicott, 1971/2005, p.120). These clients are highly
sensitive to confluence and if they sense the therapist’s References
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Aron, E. (1996). The Highly Sensitive Person: How to Thrive When
ego, this can be retraumatising.
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Stacey Klein, LCSW, is a Gestalt, somatic and psychodynamic psychotherapist and
supervisor. She has been in private practice in New York City for over twenty years where
she works with children, adolescents and adults. Stacey formerly worked as a psychotherapist
and supervisor at Mount Sinai Medical Center in New York for eleven years in a wide
range of speciality clinics including The Traumatic Stress Studies Program and The Center
for Obsessive Compulsive and Related Disorders. Her holistic approach blends traditional
psychotherapies with Eastern and Western esoteric practices and energy healing. Stacey leads
local and national trainings and workshops for clinicians, movement practitioners and the
general public on embodied living, mindfulness and the integration of body, mind and spirit.
Places she has taught include The Association for the Advancement of Gestalt Therapy, The
NY Institute for Gestalt Therapy and Barnard College. She is currently writing a chapter for
the forthcoming book edited by Gianni Francesetti, Carmen Vazquez Bandin and Elisabeth
Kerry-Reed on the Obsessive Spectrum of Experience.
Address for correspondence: staceylk22@gmail.comYou can also read
